Client Consultation Form - Spa Services at Elaine Sterling Institute

Name *

Date

Address

Apt, suite, etc.

Country

City

State

Zip code

Cell Phone

Home Phone

Date of Birth

Emergency Contact Phone

Emergency Contact Name

How did you find out about us? Name of person / website / other:

What is your goal for today’s visit and/or future visits?

Are you using any blood/skin thinning products and/or drugs?

Yes

Are you exposed to the sun daily or are you considering spending more time in the sun soon?

Yes

Do you use a tanning bed?

Yes

If yes, how often & last time:

Have you been under care of a dermatologist or other medical professional in the last year?

Yes

If yes, please explain:

Have you used an acne medication?

Yes

If yes, when and name of drug?

List any other medications you are presently taking:

List any over-the-counter medications (including vitamins, herbal supplements, aspirin, etc.) that you take regularly:

Please list any other illness or condition you are currently being treated for by a medical professional:

Have you had any recent surgery, including plastic surgery?

Yes

If yes, please explain:

Instructions

Please note that skin care treatments can have certain side effects, such as redness, rash, swelling, tenderness, etc. I have read the above information and if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician, Nail Technician or Massage Therapist to perform the skin care procedure we have discussed and will hold her/his and her/his staff harmless from any liability that may result from this treatment.
I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

I have read and understand the post-treatment home care instructions. I am willing to follow
recommendations made by my Esthetician for a home care regimen that can minimize or eliminate possible negatives reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home products/ post-treatment care, I will consult the Esthetician immediately.
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written
disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I assume all risks and outcomes of treatements and use of products. I do not hold my Esthetician, The Elaine sterling Institute, its faculty and/or it’s staff responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

Instructions

THE FOLLOWING ARE CONTRAINDICATIONS OF SERVICES AT ESI, AND CAN PREVENT YOU FROM HAVING YOUR SERVICE WITH US:
Use of Rentinols within 7 days of service
Use of Accutane within 6 Months of service
Allergies to the following: Citrus, Nuts, Shellfish, Metals, Aloe
Open Lesions or Wounds
Pregnancy
Please reach out to us if any of the above apply to you.
NAIL SERVICES: Please do NOT exfoliate within 24 hours of service.

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